PLB Provider Level Adjustment

To convey provider level adjustment information for debit or credit transactions such as, accelerated payments, cost report settlements for a fiscal year and timeliness report penalties unrelated to a specific claim or service

Position
Element
Name
Type
Requirement
Min
Max
Repeat
PLB-01
Reference Identification
String (AN)
Mandatory
1
50
1
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
PLB01 is the provider number assigned by the payer.
PLB-02
Date
Date (DT)
Mandatory
8
8
1
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
PLB02 is the last day of the provider's fiscal year.
PLB-03
Adjustment Identifier
Composite (composite)
Mandatory
1
01
Adjustment Reason Code
Identifier (ID)
Mandatory
2
2
-
Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment
02
Reference Identification
String (AN)
Optional
1
50
-
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
PLB-04
Monetary Amount
Decimal number (R)
Mandatory
1
18
1
Monetary amount
PLB04 is the adjustment amount.
PLB-05
Adjustment Identifier
Composite (composite)
Conditional
1
01
Adjustment Reason Code
Identifier (ID)
Mandatory
2
2
-
Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment
02
Reference Identification
String (AN)
Optional
1
50
-
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
PLB-06
Monetary Amount
Decimal number (R)
Conditional
1
18
1
Monetary amount
PLB06 is the adjustment amount.
PLB-07
Adjustment Identifier
Composite (composite)
Conditional
1
01
Adjustment Reason Code
Identifier (ID)
Mandatory
2
2
-
Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment
02
Reference Identification
String (AN)
Optional
1
50
-
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
PLB-08
Monetary Amount
Decimal number (R)
Conditional
1
18
1
Monetary amount
PLB08 is the adjustment amount.
PLB-09
Adjustment Identifier
Composite (composite)
Conditional
1
01
Adjustment Reason Code
Identifier (ID)
Mandatory
2
2
-
Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment
02
Reference Identification
String (AN)
Optional
1
50
-
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
PLB-10
Monetary Amount
Decimal number (R)
Conditional
1
18
1
Monetary amount
PLB10 is the adjustment amount.
PLB-11
Adjustment Identifier
Composite (composite)
Conditional
1
01
Adjustment Reason Code
Identifier (ID)
Mandatory
2
2
-
Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment
02
Reference Identification
String (AN)
Optional
1
50
-
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
PLB-12
Monetary Amount
Decimal number (R)
Conditional
1
18
1
Monetary amount
PLB12 is the adjustment amount.
PLB-13
Adjustment Identifier
Composite (composite)
Conditional
1
01
Adjustment Reason Code
Identifier (ID)
Mandatory
2
2
-
Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment
02
Reference Identification
String (AN)
Optional
1
50
-
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
PLB-14
Monetary Amount
Decimal number (R)
Conditional
1
18
1
Monetary amount
PLB14 is the adjustment amount.

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